Resident Application

Name *

First

Last

Address

Address Line 2

City

State

Phone *

Best time to call this phone number?

Morning
Afternoon
Evening

Date of Birth *

Email *

List all your alcohol/drug use and recovery dates: *

What does recovery mean to you? Please explain how recovery plays a part in all areas of your life. *

How do you see academics enhancing your recovery and supporting your objectives?

School Attending/To Be Attended:

Admission Date/Course of Study/Credits per Semester:

Current Status

How are you connected to your current recovery community (home group, treatment center, church fellowship, sponsor, etc)? How will you connect to the Janesville area recovery community? *

Current Employer: *

Position: *

How long have you worked there?

Hours per week & Income? *

Volunteer Work:

Frequency:

Daily
Weekly
Monthly
Sporadically

MEDICAL - Please identify any medical conditions that staff and/or other residents should be aware of or trained about in order to safely aid you in times of medical crisis. Please also identify any medical conditions that could potentially pose a threat to the health of others. This should include seizure disorders, diabetes, asthma, allergies, HIV/AIDS, Hepatitis, etc. Please also list any limitations due to disability or injury that may require special accommodations (i.e. physical limitations, learning disabilities, brain injury, memory impairment, hearing impairment). The presence of a medical condition or physical/cognitive disability does not constitute ineligibility for services. We ask this information for support service purposes only. *

MENTAL HEALTH - Please list any previous or current mental health diagnoses. *

MEDICATIONS - Please list any medications prescribed for medical, mental health or substance abuse needs over the last 3 years, excluding anti-biotic treatments. Listed with each, please indicate the purpose of the medication and whether the drug is a current or discontinued prescription along with the prescribing doctor’s name. *

HOSPITALIZATIONS - Please list any medical or psychiatric hospitalizations in the past 3 years. Include name of facility, dates/duration, purpose, and whether you completed the treatment/were discharged, or left before medically released. *

ADDICTIONS TREATMENT - Please list clinicians (physician, counselor...) or treatment centers that provide(ed) service to you. Identify type of treatment (detox, residential, outpatient...), dates of treatment, and treatment status (still involved, successfully completed, withdrew, etc). (copy) *

CRIMINAL JUSTICE INVOLVEMENT - Please list your involvement with criminal justice. Identify type and dates of involvement (arrests, incarceration, probation, parole). *

Name and phone number for your Probation or Parole Officer *

Activity Interests (Please check all items that interest you) *

This section is to help us understand areas of life where our potential residents would like community support, companionship, or learning opportunities through mentorships, classes, or the development of sober social clubs.

I am committed to my recovery and ongoing abstinence from alcohol and drugs (other than prescribed) *

Yes
No

I will support my peers in recovery to the best of my ability *

Yes
No

I have a minimum of 30 days in recovery from alcohol and other drugs (unless prescribed) *

Yes
No

I will work or volunteer as specified in my recovery plan *

Yes
No

I will abide by my contractual agreement with the house *

Yes
No

I will treat the house property and my housemates with respect *

Yes
No

I will take personal responsibility for notifying the house representatives of any issues or concerns while I’m a resident *

Yes
No

I will contribute to a cooperative, peer support house culture *

Yes
No

I will follow the house rules established between myself and my housemates *

Yes
No

I will give back to my community through volunteer projects *

Yes
No

I will work with mentors/coaches who can help me fulfill my personal goals and growth *

Yes
No

I hereby certify that all the information I provided in this application is accurate to the best of my knowledge. I also understand that The Micah Project will not disclose any of this application’s information, with the exception of my first and last name, to any other party without my written authorization via a specific release/disclosure form. I am aware that additional information may be necessary before final approval is made regarding this application. *

Applicant Signature & Date

Bridging the gap between treatment and community living. 608.563.1450

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